Request Received

Next steps

You are required to complete these additional forms to finalize your request.

Your Reference Code is:

Reference code for internal use only. This is not a claim number.

For your records

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Your email address *

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Request Saved

Progress Claim Form - Income Protection

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Your Reference Code is:

Please note that your form will expire on .

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Request Cancelled

Progress Claim Form - Income Protection

Your application has been cancelled and will not be processed.

Let's get started

Progress Claim Form - Income Protection

Fields marked with * are required

This form is to be completed by the Member and relates to a claim for:

Total and Permanent Disablement (TPD)

Income Protection (IP)

Both TPD & IP

This form will take approximately 20-30 minutes to complete.

This form is to be completed by or in the presence of the person who is making the claim. Please answer all questions to the best of your ability to ensure that your claim is assessed as quickly as possible.

Important note. You must:•Answer all questions fully•Acknowledge the Infomation Authority•Acknowledge the Privacy Disclosure•Tell us about all paid and unpaid work you perform in any occupation•Note that answers stating "refer to previous form" are not acceptable•Note that false or fraudulent statements or failure to advise TAL Life Limited (TAL) of any relevant information may lead to TAL refusing to pay your claim

Your details

Progress Claim Form - Income Protection

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Your policy

Claim number *

Personal details

Title *

Other

First Name *

Middle Name Initial

Surname *

Date of birth

Day *

Month *

Year *

Contacting you

Street address

Address Line 1 *

Address Line 2

Level Number

Unit Number

Street Number

Street Name

Street Type

Suburb

State

Postcode

Selected Address Field

Email address *

Best contact phone number (mobile phone preferred) *

Your claim

Progress Claim Form - Income Protection

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Claim details

What are your current symptoms and have they changed since submitting your last Progress Claim form? *

What activities are you currently able to perform?

Have you seen any other doctor, specialist or other healthcare provider since submitting your last Progress Claim form?

Yes

No

Please provide details

Practitioner

Name

Specialty *

Location *

What treatment are you currently receiving?

Have you discussed returning to work with your employer?

Yes

No

Not Employed

What was the outcome of these discussions?

Have you performed any work paid or unpaid, since submitting your last Progress Claim form?

Yes

No

Please provide details of work performed (employer, hours, duties) and income earned

Please specify the date you expect to return to work

Part-time

Full-time

Are you receiving or eligible to receive any benefits from any other organisation, insurer or government body? (eg Centrelink, DVA, CTP, workers compensation)

Yes

No

Please provide their name and details, including any amounts received

Additional Information

Progress Claim Form - Income Protection

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Additional information

Is there any other information you would like to give us at this time that may help us better understand your situation?

Online identity verification

Progress Claim Form - Income Protection

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You need to provide ID documents for us to perform online ID verification. How would you like us to verify you?

Electronic

Manual

You will be prompted to attach a copy of your driving licence and medicare in the next page.

Please select the ID type you wish to use for online ID verification

License

Medicare card

State of Issue *

License Number *

Medicare Card Number *

Position Number on Card *

Card Colour *

Valid To

Date *

Month *

Year *

Process Identity Documents

Please wait while we verify your details...

Identity Verified!

Your electronic identity check was successful.

Identity was not confirmed

Unfortunately, we were not able to confirm your identity using the information you've provided us. You can navigate back to previous sections using the top chevron menu, or the "Go back" button below. Otherwise you can proceed with a manual identity check.

Supporting documentation

Progress Claim Form - Income Protection

Fields marked with * are required

Certified copy of proof of age

File:

Copies of all medical reports

File:

Resume

File:

Completed Tax File Number Declaration form

File:

Copies of payslips since returning to work

File:

Important information

Progress Claim Form - Income Protection

Fields marked with * are required

Information authority

I hereby authorise any doctor, hospital, therapist or other medical professional who has attended me, to release to TAL Life Limited (TAL), its related bodies corporate, its agents or its representatives and to my superannuation fund or its administrator, information relevant to my policy and/or claim, with respect to any illness or injury, medical history, consultations, medications or treatment, received by me together with copies of any and all medical records. I consent to TAL and my superannuation fund collecting this sensitive information. I authorise any insurer (including workers compensation/CTP insurer), government agency or body (including Centrelink/ Department of Veterans’ Affairs), employer, accountant or other relevant holder of information, to release to TAL Life Limited, its related bodies corporate, its agents or its representatives and my superannuation fund or its administrator, information which they require for the purpose of assessing or investigating my claim. A copy of this authority is to be regarded as if it were the original signed authority.

I agree *

Privacy disclosure

The Privacy of TAL customers is important and TAL is bound by obligations imposed by current privacy laws including the Australian Privacy Principles. The way in which TAL collects, uses, secures and discloses your personal information is set out in the TAL Privacy Policy available at http://www.tal.com.au/Privacy-Policy or free of charge on request to TAL using the contact details below. GPO Box 5380, Sydney NSW 2001 Telephone: 1300 209 088 Fax: 1800 300 072 Email: customerservice@tal.com.au

Collection and use of personal information

We are bound by relevant legislation including the Privacy Act 1988 (Cth) and the 13 Australian Privacy Principles when we collect, store, use and disclose your personal and sensitive information (“personal information”).

During your claim we may collect personal information, including your name, age, gender, contact details, health information, lifestyle information, financial information, and employment information. If you do not supply the information that is required, we may not be able to provide our services to you and this may result in us being unable to continue to assess or pay a claim. In some circumstances we may take steps to verify the information we collect about you from independent sources to ensure the information is correct, up to date and complete.

Disclosure of personal information

Where we consider it appropriate during your claim, we may disclose relevant personal information to related bodies corporate and external individuals and organisations and entities including but not limited to:

•providers of medical and health services;•reinsurers, other insurers and their administrators;•any person acting on your behalf, including your financial adviser, solicitor, accountant, executor, administrator, trustee, guardian or attorney;•for members of superannuation funds where TAL is the insurer, to the trustee, or administrator of the superannuation fund as the superannuation fund owns the life insurance policy on your behalf and where appropriate to your employer for the purposes of rehabilitation assistance for return to work; and•providers of services to whom TAL outsources certain functions such as medical providers, rehabilitation providers and surveillance/investigation providers. Where it is required or authorised by law we may also need to disclose information about you to Government agencies and Courts and enforcement bodies (e.g. under Court Orders or Statutory Notices).

Generally you have a right to access information we hold about you with limited exceptions and if you wish to access information we hold about you please contact us.

We are legally required to send all communications about your policy to the policy owner. However, where the policy owner is different from the life insured, we will not communicate personal medical information about a life insured to a policy owner unless the life insured has consented or there is other lawful authority. By signing this form you consent to us collecting, using and disclosing your personal and sensitive information as detailed in our Privacy Policy at http://www.tal.com.au/Privacy-Policy and as summarised above.

Please note that this authority remains valid for the duration of your claim.

I acknowledge *

Declaration

Progress Claim Form - Income Protection

Fields marked with * are required

I hereby declare: *

•that the information in this claim form is true, complete and correct.•I understand and agree that if I make any false or fraudulent statements or fail to advise TAL Life Limited of any relevant information regarding my claim, TAL Life Limited may refuse to pay this claim or cencel my policy.